Two loci control tuberculin skin test reactivity in an area hyperendemic for tuberculosis.

Abstract

Approximately 20% of persons living in areas hyperendemic for tuberculosis (TB) display persistent lack of tuberculin skin test (TST) reactivity and appear to be naturally resistant to infection by Mycobacterium tuberculosis. Among those with a positive response, the intensity of TST reactivity varies greatly. The genetic basis of TST reactivity is not known. We report on a genome-wide linkage search for loci that have an impact on TST reactivity, which is defined either as zero versus nonzero (TST-BINa) or as extent of TST in millimeters (TST-quantitative trait locus [QTL]) in a panel of 128 families, including 350 siblings, from an area of South Africa hyperendemic for TB. We detected a major locus (TST1) on chromosomal region 11p14 (P = 1.4 x 10(-5)), which controls TST-BINa, with a lack of responsiveness indicating T cell-independent resistance to M. tuberculosis. We also detected a second major locus (TST2) on chromosomal region 5p15 (P < 10(-5)), which controls TST-QTL or the intensity of T cell-mediated delayed type hypersensitivity (DTH) to tuberculin. Fine mapping of this region identified SLC6A3, encoding the dopamine transporter DAT1, as a promising gene for further studies. Our results pave the way for the understanding of the molecular mechanisms involved in resistance to M. tuberculosis infection in endemic areas (TST1) and for the identification of critical regulators of T cell-dependent DTH to tuberculin (TST2).

Full text

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The Rockefeller University Press $30.00
J. Exp. Med. Vol. 206 No. 12 2583-2591
www.jem.org/cgi/doi/10.1084/jem.20090892
2583
Brief Definitive Report
Only an estimated 10% of individuals infected
with Mycobacterium tuberculosis develop clinical
tuberculosis (TB), whether it is primary TB,
which is typically an acute systemic disease of
children, or reactivation TB, which is typically a
chronic pulmonary disease of adults ( Stewart et al.,
2003 ). It has long been suspected that interindi-
vidual variability in progression from infection
to clinical TB disease is under tight genetic
control ( Neel and Schull, 1954 ). Genetic epi-
demiological evidence in support of this view
includes the large interpopulation variability in
both in cidence and severity of natural TB disease,
an equally remarkable interindividual variability
CORRESPONDENCE
A. Alcaïs:
alexandre.alcais@inserm.fr
OR
E. Schurr:
erwin.schurr@mcgill.ca
Abbreviations used: BCG,
Bacillus Calmette-Guérin;
DTH, delayed type hypersensi-
tivity; GWL, genome-wide
linkage; IC, information content;
LD, linkage disequilibrium; PPD,
purifi ed protein derivative;
QTL, quantitative trait locus;
SNP, single nucleotide polymor-
phism; TB, tuberculosis; TST,
tuberculin skin test.
A. Cobat and C.J. Gallant contributed equally to this paper.
E. Schurr and A. Alcaïs contributed equally to this paper .
Two loci control tuberculin skin test reactivity
in an area hyperendemic for tuberculosis
Aurelie Cobat , 1,2 Caroline J. Gallant , 3,4 Leah Simkin , 3 Gillian F. Black , 5
Kim Stanley , 5 Jane Hughes , 6 T. Mark Doherty , 7 Willem A. Hanekom , 6
Brian Eley , 8 Jean-Philippe Jaïs , 2 Anne Boland-Auge , 9 Paul van Helden , 5
Jean-Laurent Casanova , 1,2,10 Laurent Abel , 1,2,10 Eileen G. Hoal , 5
Erwin Schurr , 3,4 and Alexandre Alcaïs 1,2,10
1 Laboratory of Human Genetics of Infectious Diseases, Necker Branch, Institut National de la Santé et de la Recherche
Médicale, Paris 75015, France
2 Necker Medical School, University Paris Descartes, Paris 75015, France
3 McGill Centre for the Study of Host Resistance, and 4 Department of Human Genetics and Department of Medicine,
McGill University, Quebec H3A 2T5, Canada
5 Molecular Biology and Human Genetics, Faculty of Health Sciences, Medical Research Council Centre for Molecular
and Cellular Biology, Department of Science and Technology/National Research Centre of Excellence for Biomedical TB
Research, Stellenbosch University, Tygerberg 7505, South Africa
6 South African Tuberculosis Vaccine Initiative, Health Sciences Faculty, School of Child and Adolescent Health and Institute
of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town 7925, South Africa
7 Statens Serum Institute, Copenhagen DK-2300, Denmark
8 Pediatric Infectious Diseases Unit, Red Cross Children’s Hospital, School of Child and Adolescent Health, University of Cape
Town, Cape Town 7700, South Africa
9 Centre National de Génotypage, Institut de Génomique, Commissariat à l’energie atomique, Cedex Evry 91057, France
10 Laboratory of Human Genetics of Infectious Diseases, Rockefeller Branch, Rockefeller University, New York, NY 10065
Approximately 20% of persons living in areas hyperendemic for tuberculosis (TB) display
persistent lack of tuberculin skin test (TST) reactivity and appear to be naturally resistant to
infection by Mycobacterium tuberculosis . Among those with a positive response, the inten-
sity of TST reactivity varies greatly. The genetic basis of TST reactivity is not known. We
report on a genome-wide linkage search for loci that have an impact on TST reactivity,
which is defi ned either as zero versus nonzero (TST-BINa) or as extent of TST in millimeters
(TST–quantitative trait locus [QTL]) in a panel of 128 families, including 350 siblings, from
an area of South Africa hyperendemic for TB. We detected a major locus ( TST1 ) on chromo-
somal region 11p14 (P = 1.4 × 10 ? 5 ), which controls TST-BINa, with a lack of responsive-
ness indicating T cell–independent resistance to M. tuberculosis . We also detected a second
major locus ( TST2 ) on chromosomal region 5p15 (P < 10 ? 5 ), which controls TST-QTL or the
intensity of T cell–mediated delayed type hypersensitivity (DTH) to tuberculin. Fine mapping
of this region identifi ed SLC6A3 , encoding the dopamine transporter DAT1, as a promising
gene for further studies. Our results pave the way for the understanding of the molecular
mechanisms involved in resistance to M. tuberculosis infection in endemic areas ( TST1 ) and
for the identifi cation of critical regulators of T cell–dependent DTH to tuberculin ( TST2 ).
© 2009 Cobat et al. This article is distributed under the terms of an Attribu-
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after the publication date (see http://www.jem.org/misc/terms.shtml). After six
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mercial–Share Alike 3.0 Unported license, as described at http://creativecommons
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Genetic control of tuberculin skin test | Cobat et al.
Interestingly, several genetic epidemiological studies in
endemic areas have reported high levels of heritability for
TST, which is considered either as a binary or quantitative
trait, after M. tuberculosis exposure ( Sepulveda et al., 1994 ;
Jepson et al., 2001 ). For example, there was 92% heritability
for quantitative TST in household children exposed to an
adult TB case in Chile ( Sepulveda et al., 1994 ). These obser-
vations suggested an important contribution of host genetic
factors to resistance to M. tuberculosis infection and to the im-
mune reactions underlying TST intensity.
However, surprisingly few studies have aimed to dissect
the underlying genetic variants. A candidate gene study failed
to identify signifi cant association between quantitative TST
and IL-1 receptor antagonist ( Wilkinson et al., 1999 ). This
gene does not appear to be critically involved in TST.
after the accidental inoculation of babies with M. tuberculosis , a
higher incidence risk of the disease in fi rst-degree relatives of
TB cases as compared with fi rst-degree relatives of unaff ected
individuals, and a higher concordance rate of TB among iden-
tical twins than among fraternal twins ( Casanova and Abel,
2002 ). Studies of experimental infection in animal models, in
the mouse in particular, have provided the fi rst molecular evi-
dence underlying genetic predisposition to TB ( Schurr and
Kramnik, 2008 ). Subsequent human molecular genetic studies
have identifi ed candidate genetic risk factors for pulmonary
TB in adults ( Schurr and Kramnik, 2008 ) and have docu-
mented Mendelian predisposition, IL-12R ? 1 defi ciency in
particular, to disseminated TB in some children ( Alcaïs et al.,
2005 ). Collectively, these studies have provided the long-awaited
molecular proof of principle for the contribution of human
genetic factors to TB susceptibility.
There is also interindividual variability at the earlier initial
step of the infectious process, as ? 20% of long-exposed per-
sons appear to be naturally resistant to infection by M. tuber-
culosis ( Rieder, 1999 ). This estimate is based on the detection
of M. tuberculosis –infected and –noninfected persons by means
of the tuberculin skin test (TST) or Mantoux. The test measures
induration of the skin after intradermal inoculation of M. tu-
berculosis purifi ed protein derivative (PPD). The TST triggers
a classical T cell–mediated delayed type hypersensitivity (DTH)
reaction against mycobacterial antigens ( Vukmanovic-Stejic
et al., 2006 ). In hyperendemic areas for TB, a complete lack
of TST reactivity is therefore suggestive of a T cell–independent
resistance to infection by M. tuberculosis ( Rose et al., 1995 ).
Table I. Distribution of families according to the number of
genotyped siblings with available TST data and the number of
parents genotyped
Number of
parents
genotyped
Number of sibs per familyTotal
23456
0
1
2
22
23
29
54
0
5
7
12
0
1
3
4
0
0
1
1
4
62
62
128
33
22
57 Total
Figure 1. Distribution of TST according to age among the 350 children used for the linkage analysis before and after adjustment on rel-
evant covariates. (A) Distribution of TST values among the 350 children used for the linkage analysis. A total of 140 subjects had no measurable reaction
(red bar) and 210 subjects had TST induration > 0 mm (black bars). (B) Distribution of TST values among the 350 children according to age in years (same
color coding as in A). Note that the red dots refl ect variable numbers of subjects with TST = 0. Overall, 3, 2, 6, 2, 5, 22, 10, 20, 17, 11, 11, 13, 6, 2, 2, and 3
subjects had a TST = 0 at the ages of 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 19, and 20 yr, respectively. (C) Distribution of the Pearson residuals obtained
by logistic regression of TST-BINa on age, sex, and previous TB according to age in years. Color coding indicates those subjects with TST = 0 (red) or TST > 0
(black). As detailed in B, red dots, i.e., subjects with TST = 0, usually represent multiple persons. The two red dot outliers correspond to two subjects with
previous TB and TST = 0. (D) Distribution of the residuals obtained by Tobit regression of TST-QTL on age, sex, and previous TB according to age in years.
Color coding indicates those subjects with TST = 0 (red) or TST > 0 (black). As detailed in B, red dots, i.e., subjects with TST = 0, usually represent multiple
persons. The two red dot outliers correspond to two subjects with previous TB and TST = 0.

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Brief Definitive Report
no TST results in the low reading range (1–5 mm; Kritzinger
et al., 2009 ; Nicol et al., 2009 ; and unpublished data), making
the TST a sensitive and specifi c test for M. tuberculosis infection.
We took advantage of the unique Western Cape epidemiologi-
cal setting and undertook the fi rst GWL scan for both binary
(zero vs. nonzero) and quantitative (in millimeters) TST reac-
tivities to decipher the molecular basis of T cell–independent
resistance to M. tuberculosis in endemic areas and the molecular
basis of T cell–dependent TST intensity.
RESULTS AND DISCUSSION
The distribution of TST is bimodal
We studied 128 informative families (including 186 parents
and 350 children) comprising two to six children with avail-
able TST induration size readings ( Table I ). TST reactivity of
the 350 children is shown in Fig. 1 A . Reactivity extended
from 0 to 43 mm with a median size of 11.15 mm. Mean age
at the time of TST was 11.5 yr (SD, 4.9 yr) and the sex-ratio
was 1. As expected as a result of the cumulative exposure to
M. tuberculosis in this high incidence area, age had an impor-
tant impact on TST positivity ( Fig. 1 B ). Closer inspection of
the extent of TST reactivity showed a clear bimodal distribu-
tion with 140 individuals (40%) having a value of zero and
210 (60%) having values that approximately followed a nor-
mal distribution centered around 16 mm. Only two children
had a TST between 1 and 5 mm. Given the age distribution
of study subjects (i.e., mean age of 11.5 yr), such a high pro-
portion of TST + individuals is consistent with an annual risk
of TB infection that is >4% in the study area ( Kritzinger et al.,
2009 ). This TST distribution is strongly suggestive of a gene
or group of genes having an impact on TST positivity by
In contrast, a recent study in Ghana showed that an IL10 haplo-
type associated with low IL-10 production was signifi cantly
less frequent in PPD-negative controls than in the group of PPD-
positive controls ( Thye et al., 2009 ). A genome-wide linkage
(GWL) study in an endemic area reported suggestive linkage of
persistently low TST with chromosome regions 2q21-2q24
and 5p13-5q22 ( Stein et al., 2008 ). The absence of signifi cant
linkage peaks in the latter study might be explained by the
threshold-dependent categorization of the TST phenotype that
was used to defi ne infection status (as opposed to zero vs. non-
zero) and by the heterogeneous Bacillus Calmette-Guérin
(BCG) vaccination and/or HIV infection status of the subjects
enrolled. Better controlled studies exploiting the full range of
TST reactivity are thus needed because there is considerably
more information for linkage analysis in quantitative variation
than there is in any binary trait ( Duggirala et al., 1997 ).
To address this question, over the last fi ve years we have
collected a unique population sample of 128 large nuclear fami-
lies from a hyperendemic suburb of Cape Town, South Africa,
with an estimated TST-based annual risk of TB infection as
high as 4%, despite rates of HIV infection <2% in the pediatric
population ( Kritzinger et al., 2009 ). Out of 22 hyperendemic
countries, South Africa has the highest TB annual incidence
rate at 940/100,000, with children constituting up to 39% of
this case load ( World Health Organization, 2008 ). The Western
Cape off ers the advantage that detection of TB infection by
TST in children is not signifi cantly confounded by cross-reac-
tivities to environmental mycobacteria and BCG vaccination,
as the latter is done at birth, a situation where the impact of the
BCG vaccination on the TST is known to vanish after 12–18 mo
( Menzies, 2000 ). Indeed, in this setting there are virtually
Figure 2. Genome-wide model-free linkage analysis of TST-BINa in a panel of 128 families including 350 siblings. (A) Multipoint LOD score
(black line; left y-axis) and IC (red line; right y-axis) are plotted along the 22 autosomes. (B) Expanded view of the region with the highest LOD score on
chromosome 11. The multipoint LOD score (black line), IC at marker positions (red line), and 90% confi dence intervals for the location of the QTL (arrow
and dashed lines) are given. Left and right y-axes indicate LOD score and IC, respectively. Chromosomal positions are given in megabases (Mb).

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Genetic control of tuberculin skin test | Cobat et al.
( Lander and Kruglyak, 1995 ). The 1-LOD confi dence inter-
val for the location of the major locus (corresponding to the
90% confi dence interval for the location of the QTL under-
lying the linkage peak) spanned from 22.35 to 28.82 Mb ( Fig. 2 ,
bottom). A suggestive linkage signal was also observed on
chromosomal region 5p15 (LOD score = 2.39, P = 0.0005,
IC = 90.5%) at the same position as the TST-QTL locus (see
following paragraph). In addition, fi ve weaker linkage peaks
with P < 0.01 (i.e., LOD score > 1.17) were observed on
chromosomal regions 3p24 (LOD score = 1.40, P = 0.0056,
IC = 96.8%), 4q28 (LOD score = 1.57, P = 0.0036, IC =
94.7%), 15q26 (LOD score = 1.20, P = 0.0094, IC = 93.4%),
19q13 (LOD score = 1.83, P = 0.0018, IC = 92.4%), and
20p13 (LOD score = 1.23, P = 0.0087, IC = 93.9%; Fig. 2 ,
top). As a substantial proportion of TST = 0 persons are most
likely resistant to infection with M. tuberculosis (see Conclud-
ing remarks), these data therefore point toward the identi-
fication of one major locus ( TST1 ) controlling human
resistance to M. tuberculosis . A list of the known genes located
in the 1-LOD confi dence interval is given in Table S1 .
A major locus for TST intensity maps to chromosome
region 5p15
Results of the TST-QTL linkage analysis are shown in Fig. 3 .
A highly signifi cant linkage signal was observed on chromo-
somal region 5p15 with a multipoint LOD score of 4.00
(P = 9 × 10 ? 6 ) at position 2.70 Mb ( TST2 ). Again, this is
substantially above the commonly accepted threshold for sig-
nifi cance in GWL studies ( Lander and Kruglyak, 1995 ). The
1-LOD confi dence interval for location of the QTL was small,
spanning ? 2 Mb from 1.07 Mb to 3.23 Mb ( Fig. 3 , bottom).
itself and a diff erent gene or set of genes controlling the ex-
tent of TST reactivity. To test this hypothesis, we genotyped
? 6,000 single nucleotide polymorphism (SNPs) in all 536
individuals of the 128 nuclear families and we performed two
complementary linkage analyses. The fi rst analysis focused on
the phenotype of positivity by itself, i.e., TST = 0 versus
TST > 0 (TST-BINa). The second analysis focused on the
quantitative phenotype of extent of TST reactivity (TST
quantitative trait locus [QTL]), with a particular emphasis on
individuals with a TST > 0. Before linkage analysis, the two
phenotypes were adjusted on age, gender, and previous clini-
cal TB to remove as many environmental or nonspecifi c ge-
netic sources of TST variation as possible. Subsequent linkage
analyses were therefore performed on the resulting adjusted
residuals shown in Fig. 1 C (TST-BINa) and Fig. 1 D (TST-
QTL) that are, by defi nition, quantitative traits.
A major locus for TST positivity by itself maps
to chromosome region 11p14
We fi rst searched for genetic factors controlling TST-positive
response by itself. Results of the TST-BINa linkage analysis
are shown in Fig. 2 . Information content (IC) was very high
across all autosomes with mean genome-wide information of
94.4% (from 80.6 to 98.7%). This IC is excellent and corre-
sponds to the level only accomplished at the fi ne-mapping
stage in microsatellite-based genome scans. Linkage analysis
of TST-BINa identifi ed a signifi cant linkage signal on chromo-
somal region 11p14 (LOD score = 3.81) at chromosomal
position 26.37 Mb (IC = 91.15%, P = 1.4 × 10 ? 5 ; Fig. 2 ,
bottom). This level of statistical support exceeds the stringent
threshold of signifi cance (LOD score = 3.6) for GWL scans
Figure 3. Genome-wide model-free linkage analysis of TST-QTL in a panel of 128 families including 350 siblings. (A) Multipoint LOD score
(black line; left y-axis) and IC (red line; right y-axis) are plotted along the 22 autosomes. (B) Expanded view of the region with the highest LOD score on
chromosome 5. The multipoint LOD score (black line), IC at marker positions (red line), and 90% confi dence intervals for the location of the QTL (arrow
and dashed lines) are given. Left and right y-axes indicate LOD score and IC, respectively. Chromosomal positions are given in megabases (Mb).

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JEM VOL. 206, November 23, 2009
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Brief Definitive Report
control of TST reactivity, with TST1 controlling TST posi-
tivity by itself and, presumably, T cell–independent innate
resistance to M. tuberculosis , and TST2 controlling the inten-
sity of TST reactivity as a quantitative trait and, presumably,
the intensity of T cell–mediated DTH to tuberculin.
Fine mapping of TST2 identifi es SLC6A3 as a promising
candidate gene
Encouraged by the narrow linkage peak, we decided to fi ne
map the TST2 locus. Based on the 1-LOD confi dence inter-
val for the location of the underlying QTL for TST2 , we se-
lected a chromosomal region extending from 1.1 to 3.2 Mb
on the physical map of chromosome 5 ( Fig. 4 ) for association
studies of TST-QTL in a familial sample including the 128
nuclear families used in the linkage study and two additional
trios (one child and her/his two parents). This interval con-
tains 13 genes ( NKD2 → C5orf38 ; National Center for Bio-
technology Information build 36 [http://www.ncbi.nlm.nih
.gov]). We genotyped 133 SNPs in the targeted interval, 113
of which were considered suitable for association analysis ( Fig. 4
and Table S2 ). To optimize gene coverage, we used a geno-
centric strategy for SNPs selection. Tag SNPs were identifi ed
for each known gene including 2 kb of their 5 ? and 3 ? regula-
tory regions. To capture most genetic variation, a very strin-
gent tag-SNP selection scheme was used (r 2 = 0.8 with all
In addition to this major locus, four weaker linkage peaks
with P < 0.01 were observed in chromosomal regions 11p14
(LOD score = 1.47, P = 0.0046, IC = 93.1%), at the same
position as the TST-BINa locus 10p15 (LOD score = 1.76,
P = 0.002, IC = 93.3%), 13q21 (LOD score = 1.51, P =
0.0042, IC = 96%), and 22q11 (LOD score = 1.34, P =
0.0065, IC = 97%). Therefore, these results support the hy-
pothesis of a second major locus ( TST2 ) on chromosomal
region 5p15 controlling the intensity of TST reactivity as a
quantitative trait, i.e., the intensity of T cell–mediated DTH
to tuberculin. An interesting observation is the mirror eff ect
between the two previous analyses with a suggestive linkage
signal on chromosomal region 5p15 in the analysis of TST-
BINa and on chromosomal region 11p14 in the analysis of
TST-QTL. This is suggestive of some level of redundancy
between the two phenotypes with the most straightforward
explanation being individuals coded as 0 in both analytical
approaches. To further explore this observation, we per-
formed a linkage analysis of TST-QTL among individuals
with TST > 0 mm only. Despite a dramatic reduction in
family numbers (68 families comprising 164 children), we
still found signifi cant evidence of linkage at chromosomal re-
gion 5p15 (LOD score = 2.17, P < 8 × 10 ? 4 ). In contrast, the
linkage signal on 11p14 totally disappeared (LOD score =
0.14, P = 0.21). These results may refl ect a sequential genetic
Figure 4. Fine mapping of the 90% confi dence interval for the location of TST2 locus in a panel of 128 families including 350 siblings.
Evidence for association with TST-QTL of 113 SNPs located in the 90% confi dence linkage interval is given as ? log 10 P and plotted against SNP position
(blue diamonds). The locations of the 13 genes of this region are provided. Two intervals with no annotated genes (2–2.7 Mb and 2.9–3.2 Mb) are not
shown (//). The red lines indicate the P = 0.05 and P = 0.01 signifi cance thresholds.

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Genetic control of tuberculin skin test | Cobat et al.
tance among exposed persons. Although it is possible that this
innate resistance can be overcome by extreme exposure pres-
sure, the targeted strengthening of T cell–independent resis-
tance loci in infection susceptible persons off ers an attractive
avenue of protection from TB disease. The identifi cation of
the TST1 locus that belongs to a much larger region than
TST2 will follow the strategy successfully applied in leprosy
( Mira et al., 2004 ; Alcaïs et al., 2007 ).
Our study also provides strong evidence that a major
QTL ( TST2 ) mapping to chromosome region 5p15 is in-
volved in the control of TST extent in families living in a
hyperendemic region for TB. Consistent with our results, the
same region showed some evidence of linkage (P < 0.05)
with persistently low TST reactivity in a familial sample from
Uganda ( Stein et al., 2008 ). TST2 is the fi rst non-MHC
locus that has an impact on intensity of T cell–mediated DTH
to tuberculin. This identifi es TST2 as important immune
modulator and possible confounder in the numerous studies
that have aimed at correlating extent of TST with risk for
future clinical TB disease. A more direct link of TST2 with risk
of disease is perhaps provided by the repeated observation of
the 5p15 region as location of a sarcoidosis susceptibility
locus ( Iannuzzi et al., 2007 ). Sarcoidosis is characterized by the
immune paradox of extensive local infl ammation (granuloma
and cytokine secretion) associated with suppression of the
immune response to tuberculin ( Miyara et al., 2006 ). Multi-
ple studies have investigated the association between myco-
bacterial antigens and sarcoidosis but no clear consensus has
emerged ( Iannuzzi et al., 2007 ). Our results suggest that
human genetics could serendipitously connect the mechanisms
governing sarcoidosis and T cell–dependent DTH to myco-
bacteria. The only other example of DTH for which response
regulators have been reported in humans is the Montenegro
skin test to leishmania antigen ( Jeronimo et al., 2007a , b ).
However, none of these regulators mapped to the 5p15 (or
the 11p14) chromosomal region, suggesting that TST2
immune regulation involves an element of specifi c antigen
recognition. Our fi rst genocentric association scan of the TST2
interval identifi ed SLC6A3 as a promising candidate for
TST2 . Experimental deletion of this gene in mice resulted in
their signifi cantly reduced ability to mount a DTH reaction
against ovalbumin ( Kavelaars et al., 2005 ). SLC6A3 is related
to NRAMP1 (alias SLC11A1 ), which has previously been
shown to have a major impact on the extent of the granulo-
matous response to Mycobacterium leprae antigen ( Alcaïs et al.,
2000 ). Nevertheless, additional studies will be required to
fully understand the molecular basis of the TST2 locus.
The gene regions previously reported to play a role in
clinical TB ( Schurr and Kramnik, 2008 ), including the only
major TB susceptibility locus on chromosome 8p13 ( El
Baghdadi et al., 2006 ), do not overlap with the two main
chromosomal regions identifi ed in this study. For the TST1
locus on chromosome 11p14, this is not surprising because
genetic studies are generally done on TST-positive (i.e., in-
fected) subjects, which precludes identifi cation of infection
resistance genes. For the TST2 region on chromosome 5p15,
tagged SNPs and minor allele frequency > 5%). Because no
genes have been annotated on chromosomal intervals 2–2.7 Mb
and 2.9–3.2 Mb, few SNPs were genotyped in these chromo-
somal segments and none were signifi cant. In univariate analy-
sis, nine SNPs (rs4975579, rs6554677, rs1801075, rs250682,
rs10475030, rs11747565, rs2922061, rs1018120, and rs2232376)
were signifi cantly associated with TST-QTL at the 0.05 level
( Fig. 4 ). Analysis of the linkage disequilibrium (LD) patterns
between these nine SNPs showed no LD, supporting the hy-
pothesis of independent eff ects even though it is likely that
some of these signals are false positives (unpublished data).
Out of these nine SNPs, rs250682 located in SLC6A3 (solute
carrier family 6 member 3) displayed the strongest association
with TST-QTL (P = 0.001). Allele G of rs250682 (q = 0.36)
has a dominant eff ect and is associated with lower values of
the TST-QTL. To ensure that SNP rs250682 was responsible
for the observed association, we screened the Yoruba sample
of the HapMap database (www.hapmap.org) in a region span-
ning 5 Mb around rs250682. Only four SNPs (rs250681,
rs40358, rs403636, and rs464049) were correlated with an
r 2 > 0.5 with rs250682. All of these four SNPs are located in
the SLC6A3 gene. These results identifi ed SLCA63 as a
promising target for further study on the intensity of T cell–
mediated DTH to tuberculin.
Concluding remarks
We report in this paper that absence of TST reactivity (zero
induration) has a major human genetic component and that
the corresponding locus, TST1 , maps to chromosome region
11p14. As the risk of developing TB for persons with M. tu-
berculosis exposure but TST = 0 was previously shown to be
extremely small, such TST = 0 persons are most likely not in-
fected with M. tuberculosis ( Rose et al., 1995 ; ATS-CTC-IDSA,
2000 ). Persons who experience continued high exposure to
M. tuberculosis and display persistent lack of T cell sensitization
are much more likely to be naturally resistant to infection
with M. tuberculosis than intrinsically defi cient in mounting a
DTH response. An estimate of infection-resistant persons can
be obtained from countries where TB is highly endemic. In
such conditions, where exposure to the tubercle bacillus is in-
tense and sustained, ? 20% of individuals remain TST nega-
tive ( Rieder, 1999 ). In our families, it is not possible to
distinguish between individuals who have not been exposed
to M. tuberculosis and those who have been exposed but are
naturally resistant to infection. However, because the lack of
exposure is diffi cult to reconcile with a genetic component,
the most parsimonious explanation of our data is that the
TST1 locus refl ects T cell–independent resistance to M. tuber-
culosis infection. Consequently, a substantial fraction of TST = 0
persons in the study families must have been exposed to
M. tuberculosis but, as a result of very eff ective T cell–indepen-
dent responses, those persons were resistant to M. tuberculosis
before T cell sensitization could occur. Our fi ndings make it
likely that being spared from infection with M. tuberculosis is
not simply a matter of lack of exposure but refl ects genetically
controlled profound diff erences of T cell–independent resis-

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JEM VOL. 206, November 23, 2009
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Brief Definitive Report
diameter of induration was measured in millimeters using a set of calipers
calibrated to the nearest 0.5 mm. Two phenotypic defi nitions were used ( Fig. 1 ).
First, we dichotomized the TST distribution using 0 mm as the threshold to
study the TST positivity (TST-BINa). Second, we analyzed the extent of the
TST reactivity as a quantitative trait (TST-QTL) by Tobit regression.
Before linkage analysis, TST-BINa and TST-QTL phenotypes were all
adjusted on previous clinical TB (at least 2 yr preceding the study), sex (male
or female), and age (in years). Pearson and Tobit residuals were used for link-
age analysis of TST-BINa and TST-QTL, respectively. TST-BINa was ad-
justed by means of logistic regression ( Fig. 1 C ), as implemented in the
PROC LOGISTIC of the SAS software v9.1 (SAS institute, Cary, NC).
TST-QTL was adjusted by means of the Tobit censored regression as imple-
mented in the PROC QLIM of the SAS software, with the censoring
threshold fi xed at 0 ( Fig. 1 D ). Note that because the linkage analysis was
performed on the residuals generated by the adjustment procedure, both
phenotypes under study (TST-BINa and TST-QTL) were analyzed as quan-
titative traits. For each phenotype, the best fi tting model for the age eff ect
was determined among a set of multivariate fractional polynomials (FP)
models as proposed in ( Royston et al., 1999 ). First (FP1) and second (FP2)
degree FP models were fi tted with power p (i.e., age to the power p) for FP1
and p and q for FP2 chosen from ? 2, ? 1, ? 0.5, 0, 0.5, 1, 2, and 3, with 0
denoting log transformation. Among the 44 possible combinations, the
model providing the smaller Akaïke Information Criteria was selected. A
simple FP1 model was retained with power p = 0.5 for TST-BINa, whereas
a FP2 model was retained for TST-QTL (power p = 1 and q = 2).
Genotyping. High-density genotyping for the linkage study was performed
at the Centre National de Génotypage (Paris, France) with the linkage IVb
panel (Illumina), containing >6,000 SNPs. 11 nonpolymorphic SNPs and 79
SNPs with a call rate <80% were excluded. None of the remaining SNPs
showed departure from Hardy-Weinberg equilibrium among the founders at
the 0.001 level. Pairwise LD analysis between adjacent SNPs was performed
using Haploview software ( Barrett et al., 2005 ) in the 186 parents of our
sample. In our sample, pairwise LD between adjacent SNPs was very weak,
with most of SNPs-pairs having an r 2 < 0.1 (mean pairwise r 2 = 0.07).
Genotyping for fi ne mapping of TST2 on chromosome region 5p15
was performed at the McGill University and Genome Quebec Innovation
Centre. 133 SNPs spanning the 2.2-Mb targeted interval on chromosome
region 5p15 (i.e., the 1-LOD confi dence interval for the location of the
QTLs underlying the linkage peak) were selected on the basis of their loca-
tion within known genes in the interval and on information regarding bin
structure and allelic frequencies publicly available from the International
HapMap project (http://www.hapmap.org/). These 133 SNPs were geno-
typed on the high-throughput MassARRAY platform (SEQUENOM,
Inc.), which uses the iPLEX assay to incorporate mass-modifi ed terminal
nucleotides in the SBE step, which are then detected by MALDI-TOF MS
( Griffi n and Smith, 2000 ). 10 SNPs were excluded because they were non-
polymorphic and 1 SNP was excluded because of a call rate <80%. SNPs
with a minor allele frequency <5% were also excluded. Finally, two SNPs
that showed departure from Hardy-Weinberg equilibrium among the found-
ers at the 0.01 level were excluded (Table S1).
Internal population structure analysis. As suggested by Thompson et al.
(2006) , we checked for population substructure to minimize genetic hetero-
geneity of the sample before linkage analysis. We performed a principal com-
ponent analysis of the 5,567 autosomal SNPs in the 186 genotyped founders
of our sample as implemented in the SMARTPCA software ( Patterson et al.,
2006 ). The principle of this method is to determine the major axes of genetic
variation in the sample and to output each individual’s coordinates along axes
of variations, without formally clustering individuals into discrete population.
No population substructure was found in our data but we identifi ed fi ve out-
liers distributed in four families that were excluded from the analysis.
Family-based analysis. We performed quantitative model-free multi-
point linkage analysis on the Pearson residuals of the TST-BINa logistic
the lack of overlap with TB susceptibility genes is more sur-
prising. However, because TST2 has a strong impact on TST
induration size, which is correlated with risk of subsequent
TB disease, a further study of TST2 on susceptibility to clini-
cal TB may provide new insights into the mechanism of ad-
vancement from infection to TB disease. HLA class II genes
are validated TB susceptibility loci, and MHC alleles are
known from the mouse model to have a strong impact on
DTH ( Schurr and Kramnik, 2008 ). These observations made
the chromosome 6 HLA region a prime candidate for loci
impacting on TST induration size. Yet we failed to observe
any evidence for a role of HLA genes on TST. That the
strongest genetic eff ect on tuberculin reactivity is caused by a
non-HLA locus directly leads to the question of whether this
or other non-HLA loci will be modulators of vaccine-
induced anti-mycobacterial protective immunity. Although
the impact of the TST1 and TST2 loci on progression from
infection to TB disease is presently unknown, the two loci
which control T cell–independent resistance to infection with
M. tuberculosis ( TST1 ) and T cell–dependent intensity of tuber-
culin reactivity ( TST2 ) represent an important expansion in
our understanding of TB immunity.
MATERIALS AND METHODS
Subjects and families. Nuclear families (i.e., parents and off spring) with at
least two children were enrolled from Ravensmead and Uitsig. Ravensmead/
Uitsig (R/U) is a suburban area of Cape Town, South Africa, with a popula-
tion of 38,656 living in a 3.5-km 2 area. HIV prevalence at the time of family
enrolment was 5.2% in the overall population and <2% in the pediatric popu-
lation. The population is stable and there are few homeless people or migra-
tory workers. All individuals of the sample belong to the Cape Colored ethnic
group. There was no requirement for subjects to be household contacts of TB
cases. However, this area has a notifi cation rate of TB (all cases) of 761/100,000
and of new bacteriologically confi rmed cases of 313/100,000 ( Verver et al.,
2004 ), which is suggestive of a high level of exposure to M. tuberculosis . The
enrolment strategy was to target large households to allow later reconstruc-
tion of nuclear families. In addition, if TST reactivity was known at time of
enrollment, households that contained both strongly TST-positive and TST-
negative subjects were prioritized for enrollment, as this sampling strategy has
been shown to be the most powerful for linkage analysis.
Subjects who had had clinical TB disease in the 2 yr preceding the study
were excluded. It is of note that the distribution of TST values among siblings
of individuals who were excluded because they developed TB in the last two
years did not diff er from the overall distribution (i.e., 33 vs. 40% of null values
and mean TST of 15.8 vs. 16 mm). Individuals who were HIV positive,
pregnant, or using immunomodulatory chemotherapy were also excluded at
the time of enrolment. BCG vaccination at birth is routine in the study area
and was therefore not a confounding factor in our study because several stud-
ies have shown that the impact of BCG at birth on the TST vanishes rapidly
( Menzies, 2000 ). Similarly, all individuals belong to the Cape Colored ethnic
group, therefore limiting the risk of genetic heterogeneity. Informed consent
was obtained from all study participants. Protocols involving human subjects
were approved by the Stellenbosch University Health Research Ethics Com-
mittee (Tygerberg, South Africa), the University of Cape Town (Cape Town,
South Africa), and the Research Ethics Board at the Research Institute of the
McGill University Health Centre (Montreal, Canada).
Phenotype and covariates. TSTs were performed by specially trained health
care providers using the Mantoux method with M. tuberculosis PPD RT23 (2
tuberculin units; Statens Serum Institut, Copenhagen, Denmark). TST reactiv-
ity was read between 48 and 72 h after the skin test was performed and the

Page 8

2590
Genetic control of tuberculin skin test | Cobat et al.
Submitted: 22 April 2009
Accepted: 16 October 2009
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in Lander and Kruglyak (1995) .
It has been shown that linkage analysis using a dense SNP panel in
familial samples with missing parents could infl ate the type I error rate in
regions where SNPs display high levels of LD ( Huang et al., 2004 ). There-
fore, although the LD was very weak at the genome-wide level and between
markers underlying the two diff erent linkage peaks (mean pairwise r 2 =
0.07), we removed the SNP with the lowest minor allele frequency for each
pair of SNPs with an r 2 > 0.1. This had no impact on the LOD scores or the
IC, ruling out the possibility of TST1 and TST2 being false positive linkage
signals caused by LD patterns.
We performed family-based association testing on the 113 SNPs located in
the 2.2-Mb targeted interval on chromosome region 5p15. The analysis was
performed using the extension of the transmission disequilibrium test to quanti-
tative phenotypes as implemented in FBAT software v2.0.3 ( Laird et al., 2000 ).
Online supplemental material. Table S1 presents a list of the known genes
that are located in the 1-LOD interval of TST1 . Table S2 shows the SNPs that
were genotyped for the fi ne mapping of TST2 . Online supplemental material
is available at http://www.jem.org/cgi/content/full/jem.20090892/DC1.
We sincerely thank all members of the community who participated in this study.
We are grateful to Christine Johannisen, Magdalene Kennedy, Ronell Taylor, and
Maria Gallant for their help with fi eld work and blood collection. Gian van der
Spuy, Neal Rogers, and Mari de Klerk assisted with data capture and database
management. We are grateful to the Centre National de Génotypage for providing
the genotypes.
This work was supported by grants from the Sequella/Aeras Global Tuberculosis
Foundation and the Canadian Institutes of Health Research (CIHR) to E. Schurr and,
in part, by a grant from the Grand Challenge exploration of the Bill and Melinda
Gates Foundation to A. Alcaïs. C.J. Gallant is the recipient of a fellowship from the
CIHR Strategic Training Centre in the Integrative Biology of Infectious Diseases and
Autoimmunity. A. Cobat was supported in part by a grant from Fondation de la
Recherche Médicale, J.L. Casanova, L. Abel, and A. Alcaïs are supported by the
Assistance Publique-Hopitaux de Paris, Program de Recherche Fondamentale en
Microbiologie, Maladies Infectieuses et Parasitaires, and the Agence Nationale de la
Recherche of the Ministère Francais de l’Education Nationale de la Recherche et de
la Technologie, and J.L. Casanova was an International Research Scholar of the
Howard Hughes Medical Institute (HHMI; 2005–2008). E. Schurr is a Chercheur
National of the Fonds de Recherche en Santé du Québec and an International
Research Scholar of the HHMI.
The authors have no confl icting fi nancial interests.

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